Limited coverage criteria – cyclosporine
Last updated on May 16, 2025
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Generic name |
cyclosporine |
Strength and form |
10 mg, 25 mg, 50 mg, 100 mg capsule 100 mg/mL solution |
Special Authority criteria |
Approval period |
|---|---|
| Diagnosis of rheumatoid arthritis when a Special Authority request is submitted by a rheumatologist |
Indefinite |
| Severe ocular inflammatory disease when a Special Authority request is submitted by an ophthalmologist or rheumatologist | |
|
Extensive psoriasis involving at least 25% of body surface or having psoriasis area and severity index of at least 12 when:
AND
|
|
|
Psoriasis of the palms and/or soles severe enough to interfere with daily living or work when:
AND
|
|
|
Nephrotic syndrome when a Special Authority request is submitted by a nephrologist |
Practitioner exemptions
- Prescriptions for oral cyclosporine written by an exempted prescriber are eligible for PharmaCare coverage without submission of a Special Authority request. No Special Authority record will be created on the PharmaNet system
- For any patient who does not meet the Limited Coverage criteria, a practitioner with an exemption is required to do one of the following:
- Write on the prescription “Submit as zero cost to PharmaCare”, to indicate to the pharmacist that the prescription is not to be covered by PharmaCare; OR
- Apply for exceptional PharmaCare coverage by submitting a Special Authority request with full documentation (via fax to 1 800-609-4884). Special Authority requests are subject to review by PharmaCare and will not be covered automatically. If PharmaCare coverage is denied the practitioner must write on the prescription “Submit as zero cost to PharmaCare”
Special notes
- Special Authority requests for the treatment of moderate to severe atopic dermatitis will be considered on a case-by-case basis when coverage is requested by a dermatologist, allergist, or clinical immunologist